Obstetric Hemorrhage Care Guidelines: Haemorrhage protocol

Assessments Meds/Procedures Blood Bank

Stage 0 All births
• Risk assessment • Prepare for every patient • Active Management of 3rd Stage • Medium Risk: T&S
• Active according to hemorrhage • Oxytocin IV infusion or 10u IM • High Risk: T&C 2 U
management of risk factors • Positive Antibody
3rd stage • Measure quantitative Screen (prenatal or
cumulative blood loss current, exclude low
for every birth level anti-D from
RhoGam): T&C 2 U
Triggers: CBL ≥ 500mL vaginal / ≥ 1000 mL cesarean with continued bleeding or Signs of concealed
Stage 1 hemorrhage: VS abnormal or trending (HR ≥ 110, BP ≤ 85/45, O2 sat < 95%, shock index 0.9) or
Confusion
• Activate • Activate OB hemorrhage • IV Access: Minimum 18 gauge • Convert to High
hemorrhage protocol and checklist • Increase IV fluid (LR) and oxytocin Risk and take
protocol • Notify charge nurse, OB/ rate appropriate
• Rule out CNM, anesthesiologist • Fundal/bimanual massage precautions
hemorrhage • VS, O2 Sat q5 min Consider T&C 2 Units
causes besides • Record quantitative MOVE ON to 2nd level uterotonic if PRBCs where clinically
atony cumulative blood loss no response (see Stage 2 meds appropriate if not
q5-15 min below) already done
• Careful inspection with • Empty bladder: Straight cath or
good exposure of Foley with urometer
vaginal walls, cervix,
uterine cavity,
placenta. If intra-op,
inspect broad ligament,
posterior uterus and
placenta.

Stage 2 Triggers: Continued bleeding w/ CBL < 1500 mL or VS remain abnormal

• Sequentially • OB to bedside • 2nd Level Uterotonic: • Notify Blood Bank of
advance through • Mobilize team: 2nd OB, OB hemorrhage
medications and OB Rapid Response, - Methylergonovine 0.2mg IM (if • Bring 2 Units PRBCs to
procedures assign roles no HTN) or bedside, consider use
• Mobilize team • Continue VS & record - Carboprost 250 mcg IM of Emergency
and blood bank cumulative quantitative (if no asthma) or Release products
support blood loss q5-15 min Only if hypertensive and asthmatic (un-crossmatched)
• Keep ahead with • Complete evaluation - Misoprostol 800 mcg SL and transfuse per
volume and of vaginal wall, cervix, • 2nd IV access (minimum 18 gauge) clinical signs – do not
blood products placenta, uterine cavity • Bimanual/uterine massage wait for lab values
• Determine • Send additional labs • TXA 1 gram - may repeat in 30 min • Use blood warmer
source of including DIC panel • Vaginal: (typical order) for transfusion
bleeding • If in Postpartum: Move - Move to OR Consider activating
including to L&D/OR - Repair any tears MTP if there is
concealed • Evaluate for special continued bleeding
- D&C: r/o retained placenta
hemorrhage cases: - Place intrauterine balloon
- Uterine inversion • Intra-op Cesarean: (typical order)
- Amniotic fluid - Inspect broad ligament, posterior
embolism uterus, and placenta
- Uterine sutures
- Place intrauterine balloon
- Uterine artery ligation
Stage 3 Triggers: Continued bleeding with CBL > 1500mL or > 2 units PRBCs given or abnormal VS or
Suspicion of DIC
• Initiate Massive • Expand team • Selective embolization (IR) • Activate Massive
Transfusion - Advanced GYN • Laparotomy Transfusion
Protocol surgeon - Uterine sutures Protocol Transfuse
• Invasive surgical - 2nd anesthesia - Uterine artery ligation aggressively
approaches provider - Hysterectomy • Near 1:1 PRBC: FFP
- OR staff • Patient support • 1 PLT apheresis pack
- Adult intensivist per 4-6 units PRBCs
- Warmer for IV fluids
• Repeat coags & ABGs - Upper body warming device
• Central line
- SCDs
• Family
This table was adapted from supportHealth Care Response to Obstetric Hemorrhage: A California Quality Improvement Toolkit,
the Improving
funded by the California Department of Public Health, 2015; supported by Title V funds.
T&S= type & screen, T&C= type & cross match, CBL= calculated blood loss, VS= vital sign, MTP= massive transfusion protocol, ABGs=
Arterial Blood Gas, Shock index= [Link]